Provider Demographics
NPI:1104872852
Name:CLASSICAL PAEDIATRICS, AMC
Entity type:Organization
Organization Name:CLASSICAL PAEDIATRICS, AMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:CHRISTIAN
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:318-323-3996
Mailing Address - Street 1:3928 JEFFERSON DAVIS PL
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-1957
Mailing Address - Country:US
Mailing Address - Phone:318-325-9273
Mailing Address - Fax:318-323-5339
Practice Address - Street 1:920 OLIVER RD
Practice Address - Street 2:SUITE 1475
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5702
Practice Address - Country:US
Practice Address - Phone:318-323-3996
Practice Address - Fax:318-324-2181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA09436R174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1445797Medicaid